The surgical treatment of pulmonary tuberculosis (TB) began in the late 19th century. Following the advent of effective anti-TB medications (such as streptomycin and isoniazid) in the mid-20th century, the indications for surgical treatment gradually decreased. Nonetheless, surgical intervention remains an integral part of comprehensive TB management, particularly in recent years, as multidrug-resistant tuberculosis (MDR-TB) has become increasingly prevalent. Surgery serves as a critical option for patients with MDR-TB who fail to respond to drug therapies.
The primary principles of surgical treatment for TB involve the surgical removal of lesions or collapse therapy to promote healing. The main surgical procedures currently utilized include pulmonary resection and thoracoplasty.
Pulmonary Resection
Indications
Indications for surgery include:
- Tuberculous Cavities: These include thick-walled cavities, tension cavities, large cavities, and cavities located in the lower lobe.
- Tuberculomas: Indications include tuberculomas greater than 2 cm in diameter, caseous lesions that are unlikely to heal spontaneously, and tuberculomas that are difficult to differentiate from lung cancer. Cases involving concomitant alveolar carcinoma or malignancy arising from scar tissue also warrant early surgical excision.
- Destroyed Lung: Indications include lobar or unilateral total destruction of the lung, characterized by extensive caseating lesions, cavities, fibrosis, and bronchial stenosis or bronchiectasis, leading to significant loss of pulmonary function. These cases are often refractory to medical therapy and may act as sources of infection, with recurrent pyogenic or fungal infections.
- Tuberculous Bronchial Stenosis or Bronchiectasis: Cicatricial stenosis can lead to atelectasis of lung segments or lobes, while fibrosis in tuberculous lesions and lung tissue may result in bronchiectasis. Secondary infections may cause recurrent sputum production and hemoptysis.
- Other Indications: These include chronic fibrocavitary tuberculosis that remains unresolved despite prolonged treatment, persistent bacillary shedding after thoracoplasty, uncertain diagnoses involving suspicious pulmonary mass lesions, or unexplained atelectasis.
Contraindications
Contraindications for surgery include:
- Pulmonary tuberculosis that is spreading or in the active phase, accompanied by severe systemic symptoms, abnormal basic indicators such as erythrocyte sedimentation rate (ESR), or the presence of new infiltrative lesions at other pulmonary sites.
- Uncontrolled extrapulmonary tuberculosis affecting other organs.
- Uncontrolled severe diseases of the heart, liver, or kidneys, or poor compensatory function. - Pulmonary function tests indicating significant impairment of respiratory capacity after resecting the affected lung are also contraindications. Additionally, poorly controlled diabetes mellitus presents a relative contraindication.
Preoperative Preparation and Postoperative Management
Comprehensive cardiac, pulmonary, hepatic, and renal function assessments are necessary to determine surgical feasibility.
A detailed history of prior anti-TB drug use and treatment efficacy is required. For drug-resistant cases, new anti-TB medications may be administered, including intravenous regimens when necessary.
For patients with positive sputum smears, bronchoscopy is performed to evaluate the presence of endobronchial TB. Cases with endobronchial involvement are continued on anti-TB treatment until the condition stabilizes.
Postoperative anti-TB treatment is maintained for at least 6 to 12 months. For patients with residual intrathoracic cavities after pulmonary resection or residual lesions in the remaining lung, thoracoplasty may be considered as a simultaneous or staged procedure.
Thoracoplasty
Thoracoplasty involves subperiosteal resection of several rib segments, allowing the underlying chest wall soft tissue to collapse and promote lung collapse beneath it. This approach is a form of collapse therapy. The procedure may be performed in one stage or divided into multiple stages. Ribs are resected sequentially from top to bottom, with no more than 3–4 ribs removed at a time. Postoperative management involves compression bandaging of the chest to prevent paradoxical chest wall movement during respiration.
This surgery is mainly indicated for patients with poor general health who are unable to tolerate pulmonary resection, or in cases of extensive disease where total pneumonectomy on one side is not feasible. However, in the past 30 years, thoracoplasty has been rarely used, primarily due to its limited efficacy, the potential for postoperative spinal deformities, and the widespread adoption of pulmonary resection, which offers superior therapeutic outcomes.